My insurer refuses to cover my prescribed treatment. What can I do?
If your insurer denies your coverage, you can challenge your insurer’s decision by completing the following steps in order:
- Request an informal reconsideration;
- Appeal the decision;
- Request an external independent review; and
- File a complaint.
How do I request an informal reconsideration?
If your situation is not urgent and insurer denies your claim, the first step may be to request an informal reconsideration. The informal reconsideration process provides an opportunity for your health care provider and the insurer to discuss your medical condition in detail and, if possible, resolve the matter without a formal appeal.
Not all insurers require an informal reconsideration. Check your policy or call your insurer to determine whether your insurer mandates this step. If your insurer does require it, call or write to your insurer and ask it to reconsider its decision not to cover your treatment. This process should take no more than 30 days. If your insurer denies your claim again, request a formal appeal.
How do I request a formal appeal?
If your insurer does not require an informal reconsideration or if your insurer denied your claim after the information reconsideration process, you should request a formal appeal (also referred to as an internal appeal). This means you can ask your insurer to conduct a full and fair review of its decision.
To request a formal appeal, you should complete the following steps:
- Review the determination letter. Your insurer should have sent you a determination letter to tell you that it would not cover your claim. Review this document so you can understand why your insurer denied your claim and how you can appeal the denial.
- Collect information. In addition to the determination letter, collect all of the documents that your insurer sent to you, including your insurance policy and your insurer’s medical necessity criteria. “Medical necessity criteria” refers to your insurer’s policy for determining whether a treatment or service is necessary for your condition.
- Request documents. If your insurer did not send you the determination letter, your policy, the medical necessity criteria, or instructions and forms for filing an appeal, call your insurer and request these documents. You can use Arizona’s “Health Care Appeal Request Form” located here.
- Call your health care provider’s office. Contact your health care provider’s office to ask for help with the appeals process. Someone in his or her office might help you fill out the forms to request an appeal and draft a strong appeal letter.
- Submit the appeal request. You or someone in your health care provider’s office should submit the appeal forms along with the letter from your health care provider and any additional information that your insurer requested. Be sure to follow your insurer’s instructions closely and make a copy for your own records of all documents you or your health care provider submitted to the insurer.
- Follow up. Follow up with your insurer regularly until you hear back. Be sure to keep a record of the name of any representative you speak with about the appeal, the date and time you spoke with that person, a confirmation number for the call, and a summary of your discussion.
You must request a formal appeal within 60 days of receiving your last denial letter.
How long should the formal appeals process take?
The formal appeals process should take a maximum of 30 days if you have not yet received the requested service or treatment and a maximum of 60 days if you have received the service or treatment but are waiting for reimbursement.
In which circumstances can I apply for an external independent review?
During an external independent review, an independent third party reviews your insurer’s decision. Your insurer will no longer have the final say over whether to approve a treatment or pay a claim.
If your insurer denies your claim after conducting a formal appeal, you can request an external independent review of the insurer’s decision. You must file your written request for an external independent review within four months from the date that your insurer sent you the last decision.
What if my situation is urgent?
Expedited medical review. If your situation is urgent, you can skip the informal reconsideration process and request an expedited medical review. Your situation is urgent if a delay in treatment could cause a significant negative impact on your medical condition. To request an expedited medical review, ask your health care provider to send the “Provider Certification Form for Expedited Medical Reviews” to your health insurer along with supporting documentation. Your health insurer should make a decision within one business day after receiving the form.
Expedited appeal. If your insurer denies your claim again, ask your health care provider to submit a written expedited appeal to your insurer. Your health care provider should include any additional reasons and supporting documentation for the requested services. Your health insurer should make a decision within three business days of receiving the written expedited appeal.
Expedited external independent review. If treatment is denied again, you have five business days to request an expedited external independent review.
How do I request an external independent review?
You should submit your request for a standard or an expedited external independent review to your health insurer, which will then forward the request and all documentation related to your appeal to the Arizona Department of Insurance (“Department”).
The Department will then select an independent third party to review your insurer’s decision. The reviewer’s decision is binding on both you and your health insurer. You should include any new information in your request for an external appeal.
How long will the external independent review process take?
The external independent review process should take no more than 45 days. If you request an expedited external independent review, the process should take no longer than four business days after your request is received.
How do I file a complaint?
If you are an Arizona resident and your insurer denies your coverage after the external independent review process, you can file a complaint with the Department.
Your complaint should include the following information:
- The name, address, email address, and telephone number of the person filing the complaint (“Complainant”);
- The name of the insured individual, if different from the Complainant;
- The names of any other parties involved in the claim (for example, the plan administrator);
- The name of insurance company and the type of insurance;
- The state where the insurance plan was purchased;
- Claim information, including the policy number, certificate number, claim number, dates of denial, and amount in dispute;
- The reason for and details of the complaint; and
- What you consider to be a fair resolution.
You should submit any letters, emails, forms, insurance policies, proof of payment, or other documents that will help the Department assist you with your complaint.
How to submit
Arizona Department of Insurance
Consumer Affairs Division
2910 North 44th Street, Suite 210
Phoenix, AZ 85018-7269
What happens after the Department receives my complaint?
The Department will typically research, investigate, and resolve individual consumer insurance complaints. The Director of the Department may examine your account, records, documents, and transactions. He or she may also question witnesses, request additional documents from other parties, and hold a hearing. The Department will then provide you with a decision.
Who should I call if I have any questions about filing a complaint?
You can contact the Department at (602) 364-2499 or (800) 325-2548 if you live in Arizona but are outside the Phoenix area. The Department telephone line is open from 8:00 a.m. to 4:00 p.m. Monday through Friday.
 Appealing a Health Plan Decision: External independent review, HealthCare.gov, https://www.healthcare.gov/appeal-insurance-company-decision/external-review/ (last visited Nov. 26, 2016).
 Ariz. Rev. Stat. Ann. §§ 20-160, 20-161 (2016).